CM in the home reduces ED, inpatient visits

Hospital focuses on frail elderly patients

In three months following participation in a program that provides care management and outpatient services to the frail elderly in their homes after discharge, patients in Dartmouth Hitchcock Regional Medical Center's Bridge Program experienced a 41% decrease in emergency department visits and a 27% decrease in inpatient admissions compared to the three months before the program began.

"Our data show a continued trend toward the same kind of outcomes. We feel like our program has made a difference in a lot of our patients' lives. Their feedback shows that they are very satisfied with the care they are receiving," says Ellen F. Thompson, MS, RN, interim director of care management at the 396-bed tertiary care hospital located in Lebanon, NH.

The purpose of the program is to bridge the gap between the hospital and the community and reduce the chances of patients being rehospitalized by working as a team with the patient, family, the primary care physician, and community organizations that provide support.

The majority of patients in the Bridge Program are between 75 and 84 with multiple health care and psychosocial needs.

The program coordinates care for about 35 to 40 patients at a time and follows the patients for four to six weeks following discharge.

The Bridge Program is staffed by a nurse practitioner certified in geriatric medicine, two part-time physicians (one of whom is a board-certified geriatrician), a master's-prepared social worker continuing care manager, and an RN continuing care manager.

Using the information gained in a complete medical and functional assessment, the team provides education to the patients and their families about their disease process and discusses additional resources available to support their often complex needs.

The team strives to help patients settle back into living at home by offering medical visits and arranging for community resources, Thompson adds.

Each patient receives a visit from one of the physicians or the nurse practitioner. These visits typically focus on clinical issues, such as complicated medical plans of care, new diagnoses, or multiple medical changes.

The continuing care managers support patient, family, and provider team coordinator, Thompson adds.

"They provide information and support to help patient access community resources and systems, complete functional health status and risk assessments, identify health promotion and risk avoidance strategies, advocate and negotiate for needed health and social services, facilitate transitions with and across care settings, identify system issues, and initiate improvement efforts," she says.

"We try to have the same clinician follow the patients to create continuity in care and try to limit the number of team members who see a patient. However, if patients have an emergent need, we send out any clinician who is available," Thompson says.

The Bridge Program was developed as an outgrowth of the hospital's initiative to reduce readmissions, build its geriatric services, and provide patient- and family-centered care, says Licia Berry-Berard, MWS, LCSW, continuing care manager for the Bridge Program and manager of patient- and family-centered care.

The hospital recruited senior citizens and their families to participate in focus groups to determine how the hospital could best serve its senior population. Participants were recruited through local senior centers and assisted-living facilities, and through advertisements in the newspapers.

"We presented seven different ideas for programs that the hospital was considering, asked the seniors which they would utilize and what they thought were the positive and negative points about each program. The Bridge Program rated near the top of the list of services folks thought would be beneficial to them," Berry-Bernard says.

After the focus groups concluded, some of the participants joined the development team to review the program outline and contribute to the implementation of the Bridge Program, she says.

Patients who are eligible for the program are identified while they are in the hospital, usually by discharge planning nurses working with the hospital's hospitalist staff.

To be eligible for the program, patients must live within a 30-mile radius of the hospital and live alone or with an elderly spouse. Elderly patients who have experienced acute changes in functional status, multiple hospital admissions, who take four or more medications for a chronic illness, or who have terminal illnesses or severe symptoms but are not ready for hospice, are also eligible. Other criteria include frailty, dementia, and a high risk for readmission.

"We also offer the program to any patient the discharge team feels needs more education, additional supervision, or multiple changes in the plan of care," Berry-Berard says.

When patients are identified as being eligible for the program, the clinical resource coordinator (discharge planner) describes the program to the patient and caregivers and confirms that he or she wants to participate. The information is included in the discharge summary.

The Bridge Program administrative assistant calls the patient after discharge and sets up a home visit by one of the members of the Bridge team.

The clinician making the initial visits completes a medical review, looks at support at home, determines if the discharge needs are being met, and determines what other issues the patients may have. The initial assessment typically takes about 45 minutes.

In addition, the social worker or the RN continuing care manager conducts a more comprehensive functional assessment that takes about an hour and a half.

The functional assessment includes screening for activities of daily living, anxiety, depression, medication, nutrition, gait, and alcohol or drug use.

"This assessment gives us a baseline that helps us determine what kind of resources and support the patients have, what they need, and to identify what resources may be available to them," Berry-Berard says.

The hospital bills Medicare for the nurse practitioner and the physician visits, but cannot bill for the continuing care managers' time.

The continuing care managers help the patients sign up for Medicaid or medication assistance programs when appropriate, and connect them to community resources such as meals on wheels, home and community-based care programs, and Lifeline.

"A very important part of this intervention is a check with the patient and family of their medications and the process they use to take their medications," she says.

The team also makes sure that patients have advance directives in place and discusses end-of-life issues with the patients and family members when appropriate.

"We have found that a fair number of patients who aren't ready for hospice yet may need some support in transitioning to that level of care. As a social worker, I can provide counseling and support and educate patients and family members about palliative care and hospice," Berry-Berard says.

Many people are not aware of their options when they near end of life and have a preconceived notion about what hospice means, Thompson points out.

"It really helps to have someone who can talk with them about how to proceed and what support they need to stay in their home. If the family can't provide the support, they can talk about other options. The continuing care managers can take more time with these issues than physicians can provide during an office visit," Thompson says.

If the patients don't already have a primary care physician, the Bridge team helps them identify one. They work with the patient's primary care physician on ensuring that the patients can safely remain in their homes.

"A big focus of the program is building relationships with primary care physicians and letting them know that what we want to do is to provide a safe transition from the hospital to home. Physicians recognize that patients are leaving the hospital much sicker than in the past and that they still need a lot of care when they go home," Thompson says.

The physicians see the Bridge Program as an extension of hospitalization. The Bridge team visits patients in the home, helps them get stabilized, then turns them back over to the primary care physician.

"We are the physicians' eyes in the patient's home. It's not often that physicians have the opportunity to know how their patients function when they are at home. With complex patients, they appreciate having another pair of eyes do a home assessment and look at the treatment plan," she adds.

The team members typically make between five and 10 visits with a patient, depending on the patients' needs.

On rare occasions, on the initial visit, the team member may determine that the patient understands his or her medication, has all the needed support in place, and has a follow-up appointment with the primary care physician. In that case, the Bridge team provides the primary care physician with an assessment of the patient and the home situation and closes the case.

"Sometimes patients are ready to move into hospice shortly after discharge from the hospital. We bring in someone from hospice to talk to the patient and arrange care," Berry-Berard says.

The Bridge Program team is making a comprehensive review of the program with the help of leadership at the Dartmouth Centers for Health and Aging.

The scheduling for the Bridge Program team is handled by an administrative assistant who tries to group the patients assigned to a particular team member by geography.

Berry-Berard typically sees four to five patients a day and carries a case load of 14 to 15 patients at a time.

"Since the continuing care managers don't bill for our services, we are flexible enough to do what the patient needs. We might see a new patient three times in one week if they are really struggling," she says.